Anal sex
Reviewed by Dr David Delvin, GP and family planning specialist
Anal sex has always been a highly controversial subject, and the controversy that surrounds it looks set to continue into 2012 because evidence accumulates that this practice may sometimes lead to anal cancer.
What is it?
Anal sex means sexual activity involving the bottom – in particular, the type of intercourse in which the penis goes into the anus. It's often referred to as 'rectal sex'.
Anal sex does carry considerable health risks, so please read our advice carefully.
Our impression is that anal sex has become rather more common in heterosexual couples, partly because they have watched 'blue movies' in which this activity so often occurs.
One small study carried out in 2009 suggested that in the UK, 30 per cent of pornographic DVDs feature rectal intercourse. Often, it is presented as something that is both routine and painless for women. In real life, this is not the case.
Other types of sexual activity which involve the anus include:
- 'postillionage' – which means putting a finger into the partner's bottom
- insertion of 'butt plugs' – which are sex toys that dilate the anal opening and create a sensation of fullness
- use of vibrators on or in the anus (please see cautionary note below)
- 'rimming' – which is oral-anal contact; this carries a significant risk of infection
- 'fisting' – which means putting the hand into the rectum; this activity is rare among heterosexual couples.
Taboos and infection
There are taboos surrounding the various types of anal sex – and particularly anal intercourse.
These may arouse strong feelings of moral indignation, guilt and anxiety.
It is important to remember that while some people find these activities repugnant, others may find them stimulating, exciting and a normal part of their sexual intimacy.
Research shows that, whether we like it or not, the anal area is equipped with many erotic nerve endings – in both men and women.
So it's not surprising that many couples (including a lot of heterosexual ones) derive pleasure from some form of 'bottom stimulation'.
What about infection? Most sexual activities carry a risk of transmission of sexually transmitted diseases (STDs) ranging from gonorrhoea and herpes to hepatitis Band HIV.
There's evidence that anal intercourse carries a higher transmission risk than almost any other sexual activity. Information about these risks is given below.
Consent
What consenting adults enjoy sexually in the privacy of their homes is their own business provided that the law does not prohibit it.
The key issues are legality and consent. In the UK, anal intercourse is now a legal activity between consenting men and women aged 16 and over, in both heterosexual and homosexual relationships, except in Northern Ireland where it's 17 and over.
In some countries it is still a criminal offence punishable by long custodial sentences, and corporal or even capital punishment. It remains forbidden in some states of the USA, though in practice a Supreme Court decision of 2003 appears to invalidate these state laws.
Anal intercourse is legally forbidden in some former colonies of Britain, notably in the West Indies.
Consent freely given by both partners is an essential feature of sexual activity in a loving relationship. Many individuals, both men and women, may have secret fantasies involving anal intercourse but feel unable to discuss them with their partner.
Some may try and pressurise their partner to have anal intercourse, even though the partner does not share their interest. Some partners will reluctantly acquiesce, others may be pressured or even physically forced to allow it.
Forcing or pressurising a partner to submit to an activity that they find distasteful or degrading is completely unacceptable behaviour.
Intoxication with drugs or alcohol is associated with lowering inhibitions and experimentation with unusual or unsafe sexual behaviour – and can lead to serious consequences.
Some male gay couples use the drugs known as 'poppers' (nitrates) to try to relax the anal sphincter and so make penetration easier. But these agents do carry some risk of side-effects.
It should be remembered that in the absence of freely given consent, the very serious criminal offences of assault and rape are committed.
Therefore, it's essential that both partners agree that they wish to try anal sex as a part of their sexual repertoire and that they are sure of the legal position on anal intercourse in the country that they are in.
Who does it?
There is a common misconception that anal sex is practised almost exclusively by gay men. This is certainly not the case.
It's widely claimed that one third of gay couples do not include anal intercourse in their lovemaking. According to one estimate, about a third of heterosexual couples have tried it from time to time.
It's thought that about 10 per cent of heterosexual couples have anal intercourse as a more regular feature of their lovemaking.
In absolute numbers, more heterosexual couples have anal sex than homosexual couples, because many more people are heterosexual.
Is it safe?
Anal sex, if practised with care, is possible for most couples.
It does, however, carry health risks and there are safer sexual practices that couples can enjoy.
The main health risks, which affect both heterosexual and homosexual couples, are described below.
- Human immunodeficiency virus (HIV): there is no doubt that anal intercourse carries a greater risk of transmission of HIV – the virus that can cause acquired immunodeficiency syndrome (AIDS) – than other sexual activities, particularly for the receptive partner.
- Human papilloma virus and warts: this virus can be transmitted during anal intercourse and that may lead to anal warts.
- HPV and anal cancer: unfortunately, certain strains of HPV virus do have carcinogenic (cancer-provoking) potential. There are some types of HPV that cause cancer of the cervix in women and probably also cancer of the throat. Round about the beginning of the present century, research showed that HPV could be isolated from the tissues of many anal cancers. By 2008, it became clear that people who had been anally penetrated by multiple partners were unusually likely to get carcinoma of the anus. A Danish study has recently suggested that gay men may have a 17-fold increase in risk of anal cancer – but close inspection of this paper reveals that the number of people involved was very small. So the case is not quite proven yet, but there are enough data to suggest that if you are going in for anal intercourse, it's safest to do it with only one regular partner.
- Hepatitis A (infectious hepatitis): this is a viral infection that can cause jaundiceand abdominal pain. Hepatitis A is not usually a life-threatening illness, although sufferers can feel quite ill. It can be transmitted by oral-anal contact.
- Hepatitis C: is a cause of progressive and sometimes fatal chronic liver disease. Hepatitis C may be transmitted by anal intercourse, although this seems to be a rare occurrence. Sharing of equipment for intravenous drug use is a far more important risk for transmission.
- Escherichia coli (E. coli): may sometimes cause mild to severe, or even (very rarely) fatal, gastroenteritis. It is one of many viruses and bacteria that can be transmitted by oral-anal contact. Some E. coli strains (uropathic E. coli) can also cause urinary tract infections (UTIs), ranging from cystitis to pyelonephritis – a serious kidney infection. E. coli very readily crosses the short distance between the female anus and the female urinary opening, so causing a urinary infection. Anal intercourse can facilitate this transfer, particularly if it is immediately followed by vaginal intercourse.
Protection
Avoiding anal sex altogether is of course the best way of avoiding these risks.
There are other, safer sexual practices that can be exciting and rewarding, but many couples may still wish to try the anal route.
The use of condoms and water-based lubricants, such as K-Y Jelly, will offer some protection.
Other lubricants may cause condoms to split, as will over-energetic thrusting without adequate lubrication.
Specially toughened condoms designed for anal intercourse may offer more protection.
How to have anal intercourse safely
Anal intercourse involves the penetration of the anus and rectum with the erect penis for the purpose of sexual stimulation.
It is possible for both men and women to 'receive' it, although care is needed for it to be safe and comfortable.
Ensure the anal area is clean and the bowel is empty. This is important both aesthetically and practically. If the bowel is empty, there is no risk of the receptive partner passing faeces.
First try gently inserting a lubricated finger, perhaps covered by a condom or glove into the anus. This will enable the receiving partner to find out whether penetration is comfortable and enjoyable. Having managed to accommodate one finger, you can run it around the anal canal – gently stretching it. This must be done delicately so as not to cause pain or injury.
If this is successfully achieved, the couple may agree to try with a well-lubricated penis or with a butt plug (a broad-based anal dilator), dildo or vibrator (see below about the risks of sex aids and anal sex).
Gentleness, care, adequate lubrication and anal relaxation are required, not the insertive partner pushing harder! If condoms are used for penile penetration, which is advisable to reduce the risk of sexually transmitted disease, it is important to use a water-based lubricant. The insertive partner must be gentle with any thrusting, so as to give the receptive partner time to allow the sphincter to relax. With time and practice, this may become easier.
Drugs and anal sex
- Muscle relaxant drugs (amyl nitrate, butyl nitrate, glyceryl trinitrate) have been tried to make anal intercourse easier or more comfortable. We do notrecommend this. Amyl nitrate 'poppers' sold in small bottles for inhalation, are popular in the gay community and have a reputation both for enhancing the intensity of orgasm and helping relax the anal sphincter. There's no real evidence to support these assertions and its use is not recommended by medical authorities. It is important to remember that amyl nitrate is a potent drug with many side-effects, including facial flushing, headaches, dizziness and low blood pressure, which may lead to faintness and loss of consciousness. Amyl nitrate, when taken with Viagra (sildenafil), may cause a catastrophic drop in blood pressure with potentially fatal consequences. Other nitrates may have the same effect. All erection-inducing drugs, including Viagra (sildenafil), Cialis (tadalafil)and Levitra tablets (vardenafil), can be very dangerous if you are using nitrates.
- Local anaesthetics, such as lignocaine (lidocaine) cream or even locally applied cocaine, have been used to reduce anal pain during intercourse. Again, we strongly advise against this. By numbing the anal skin there is a real risk of causing serious injury to the anal sphincter through over-vigorous thrusting. By following the steps above it is possible to gently dilate the sphincter for comfortable intercourse. The purpose of pain is to make us aware that we are causing injury and, therefore, local anaesthetics should be avoided. Another problem with local anaesthetics is that they may make the penis of the insertive partner numb. This may lead to problems with erection, orgasm and ejaculation.
Fisting
This means putting the whole hand into the rectum.
With adequate relaxation it's physically possible, and it may be acceptable and enjoyable for some couples. But the diameter of the hand is so much greater than that of the penis that there's an increased risk of anal injury. For that reason, we do not recommend this practice.
In reality, anal fisting is very rarely used by heterosexual couples.
Rimming
Rimming involves oral contact with the anus for sexual stimulation. This involves a high risk of transmission of infection. So we cannot recommend this practice.
Sex aids and anal sex – a cautionary note
Some couples like to use sex aids for insertion into the anus. Certain individuals may use them for solitary sexual stimulation.
The same principles apply as for genital insertion in that relaxation is essential. Sex aids must be kept clean and washed carefully between use. Condoms may be placed over sex aids as an additional precaution.
One additional risk from the use of sex aids in anal sex is that of losing the aid into the rectum.
Some medical school pathology museums have a wide selection of novel foreign bodies recovered from the rectums of both men and women, ranging from vibrators to milk bottles.
Human ingenuity seems to know no bounds in this area, but it is incredibly foolish to insert potentially breakable objects into the anus and terrible injuries may result.
If you do lose a sex aid into the rectum you should attend the Accident and Emergency department of your local hospital as soon as possible, however embarrassing it may be. The situation will only get worse if it is neglected and the object may break or become more difficult to recover.
In general, you should only use a sex aid which is designed for the anus. Butt plugs and anal vibrators have a broad base, which makes it difficult to 'lose' them inside the rectum.
Vaginal vibrators are not designed in this way, and can easily slip inside and buzz their way up the colon. Some have been recovered by surgeons from far inside the abdomen.
If they are still vibrating when the patient arrives at the hospital, they produce an interesting but alarming phenomenon called 'the rotating umbilicus sign'. Don't let this happen to you.
Based on a text by Dr John Dean, specialist in sexual medicine, and Dr David Delvin, GP and family planning specialist
Last updated 15.12.2011
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this is interesting. some couples do like anal sex.